Search

Background: Paediatric peripheral intravenous catheter (PIVC) insertion using traditional landmark insertion technique can be difficult. Aim: To systematically review the evidence comparing landmark to ultrasound guidance for PIVC insertion in general paediatric patients. Study design: Cochrane methodology to systematically search for randomised controlled trials comparing landmark to ultrasound‐guided PIVC insertion. Data sources Cochrane Central Register of Controlled Trials, US National Library of Medicine, Cumulative Index to Nursing and Allied Health, Embase. Data extraction: English‐language, paediatric trials published after 2000, reporting first‐attempt insertion success, overall PIVC insertion success, and/or time to insert were included. Central venous, non‐venous and trials including only difficult intravenous access were excluded. Data were independently extracted and critiqued for quality using GRADE by three authors, and analysed using random effects, with results expressed as risk ratios (RR), mean differences (MD) and 95% confidence intervals (CI). Registration (CRD42020175314). Results: Of 70 titles identified, 5 studies (995 patients; 949 PIVCs) were included. There was no evidence of an effect of ultrasound guidance, compared to landmark, for first‐attempt insertion success (RR 1.27; 95% CI 0.90–1.78; I2 = 88%; moderate quality evidence), overall insertion success (RR 1.14; 95% CI 0.90–1.44; I2 = 82%; low quality evidence), or time to insertion (mean difference −3.03 min; 95% CI −12.73 to 6.67; I2 = 92%; low quality evidence). Limitations: Small sample sizes, inconsistent outcomes and definitions in primary studies precluded definitive conclusions. Conclusions: Large clinical trials are needed to explore the effectiveness of ultrasound guidance for PIVC insertion in paediatrics. Specifically, children with difficult intravenous access might benefit most from this technology. [ABSTRACT FROM AUTHOR]

Aim: Central venous access devices (CVADs) are vital medical devices to support the treatment of paediatric cancer; however, device occlusion is common, which disrupts treatment. This study aimed to improve the identification and management of CVAD occlusions in children with cancer, as well as to identify the demographic, clinical and device characteristics associated with increased risk for CVAD occlusion. Methods: A pre–post‐implementation study was conducted at a metropolitan paediatric oncology facility in Australia, using the Theoretical Domains Framework. Patients with a CVAD for anti‐cancer therapy were prospectively followed for occlusive events pre‐ and post‐ the implementation of clinical resources to support the identification and management of CVAD occlusive events. CVAD occlusion and management data were collected and compared pre‐ and post‐implementation. Risk factors for CVAD occlusion were described by mixed‐effects Poisson regression and incident rate ratios (IRR). Results: A total of 133 CVADs were inserted into 131 patients for a total of 6784 catheter days. The incidence of CVAD‐related occlusion pre‐implementation was 59.7 (95% confidence interval (CI) 51.4–69.0, per 1000 catheter days); compared to 31.6 (95% CI 26.4–37.6); P < 0.01) post‐implementation of clinical resources. In multivariate models, other than post‐implementation phases (IRR 0.51 (95% CI 0.32–0.81)), only neutropaenia significantly increased the risk of CVAD occlusion (IRR 2.14 (95% CI 1.15–3.97)). Conclusion: CVAD occlusions in paediatric oncology are common. The development and implementation of CVAD occlusion resources to guide the identification and management of occlusive episodes led to a significant decrease in occlusive events. [ABSTRACT FROM AUTHOR]

Aim: To describe practice evolution, complications and risk factors for multiple insertion attempts and device failure in paediatric central venous access devices (CVADs).Methods: A paediatric retrospective cohort study using prospectively collected data from CVAD database 2012-2014. Data included were patient (i.e. age, condition), insertion (i.e. indication, device, technique) and removal (complications, dwell). Descriptive statistics and incidence rates were calculated per calendar year and compared. Risk factors for multiple insertion attempts and failure were explored with logistic regression and cox regression, respectively.Results: A total of 1308 CVADs were observed over 273 467 catheter-days in 863 patients. Multiple insertion attempts remained static (14%) and significantly associated with non-haematological oncology (odds ratio 2.19; 95% confidence interval (CI) 1.08-4.43), respiratory (3.71; 1.10-12.5), gastroenterology (4.18; 1.66-10.5) and other (difficult intravenous access) (2.74; 1.27-5.92). CVAD failure decreased from 35% (2012) to 25% (2014), incidence rate from 1.50 (95% CI 1.25-1.80) to 1.28 (1.06-1.54) per 1000 catheter-days. Peripherally inserted CVAD failure was significantly associated with lower body weight (per kilogram decrease, hazard ratio (HR) 1.02; 95% CI 1.00-1.03), cephalic vein (1.62; 1.05-2.62), difficult access (1.92; 1.02-3.73), sub-optimal tip placement (1.69; 1.06-2.69) and gastroenterology diagnosis (2.27; 1.05-4.90). Centrally placed CVAD failure was significantly associated with younger age (per year, HR 1.04; 95% CI 1.00-1.07), tunnelled device (3.38; 2.41-4.73) and gastroenterology diagnosis (1.70; 1.06-2.73).Conclusions: While advancement in CVAD practices improved overall CVAD insertion and failure outcomes, further improvements and innovation are necessary to ensure improved vessel health and preservation for children requiring CVAD. [ABSTRACT FROM AUTHOR]

Aim: Tonsillectomy procedures are a core element of paediatrics; however, perioperative management differs. This study aimed to describe tonsillectomy management, including the burden of pain, nausea and delayed recovery.Methods: A prospective cohort study was undertaken through an audit of tonsillectomy perioperative practice and recovery and survey interviews with family members 7-14 days post-surgery. The study was undertaken at an Australian tertiary referral paediatric hospital between June and September 2016.Results: The audit included 255 children undergoing tonsillectomy, with 127 family members interviewed. Most participants underwent adenotonsillectomy (n = 216; 85%), with a primary diagnosis of obstructive sleep apnoea (n = 205; 80%) and a mean age of 7 years (standard deviation; 3.9). A variety of intra-operative pain relief and antiemetics was administered. Pain was present in 29% (n = 26) of participants at ward return, increasing to 32-45% at 4-20 h and decreasing to 21% (n = 15) at discharge. A third of the children (32%; n = 41) had moderate to severe pain at post-discharge interview, and 30% (n = 38) experienced nausea at home. Most parents (82%; n = 104) were still giving regular paracetamol at 7 days post-operatively, and 31% (n = 39) had finished their oxycodone. Of the participants, 14% (n = 26) presented to the emergency department within 7 days of discharge; 8% (n = 20) of the total cohort were re-admitted.Conclusions: There was variety in perioperative and post-discharge care. Pain scores were infrequently documented post-tonsillectomy, and parents are generally dissatisfied with the management of post-operative pain and nausea. Further research is needed to provide a more consistent approach to perioperative management to promote recovery. [ABSTRACT FROM AUTHOR]

Aim: To improve paediatric peripheral intravenous catheter (PIVC) care through the implementation of care bundles.Methods: A pre-post study using mixed methods (clinical audit, staff survey, parent interviews) in 2016 at a tertiary paediatric hospital in Brisbane was conducted to evaluate the effectiveness of a PIVC insertion and maintenance bundle to improve PIVC insertion, promote function and support practice. Participants included children with PIVC, parents and staff inserting and managing PIVCs. A mnemonic care bundle, SUCCESS PIVCS (At insertion: Skills, Understand and prepare, Consent, Clean site, Escalate, Secure, Sign and document. During management: Prompt removal, Inspect hourly, Vein patency, Clean hands and Scrub the hub), was developed and implemented via visual aids, workshops and change champions. During audit, PIVC first-attempt insertion success, PIVC failure, PIVC dwell, escalation to senior clinicians and insertion and management procedures were measured.Results: Pre-implementation audit (n = 102) and survey (n = 117) data described high rates of PIVC failure (n = 50; 49%), difficulty obtaining equipment (n = 64; 55%) and pressure to insert (n = 50; 43%). Parent interviews (n = 15) identified lack of communication, fear, appreciation of skilled technicians and technology and care giver roles as key to improving the experience. After implementation first-attempt insertion success (45 vs. 62%; risk ratio 1.37, 95% confidence interval 1.05-1.78), first-attempt escalation to senior clinicians (junior doctor 72 vs. 41%; P = <0.001) and median PIVC dwell (40 vs. 52 h; P = 0.021) improved.Conclusion: This multi-level care bundle demonstrated improvements in the insertion and management of PIVCs; however, PIVC failure remained high. [ABSTRACT FROM AUTHOR]

Aim: To identify the prevalence, management and complications associated with central venous access devices (CVADs) within Australian paediatric facilities, providing a map for clinicians, researchers and managers to focus solutions.Methods: A point prevalence audit and survey of CVAD practices in Australian tertiary paediatric hospitals between September and November 2015, using validated data collection tools.Results: Across the six sites, 1027 patients were screened with CVADs prevalent in 26.1% (n = 268), and 261 CVADs in 248 patients available for audit. Variations in management were evident with dressings not meeting the basic criteria of clean, dry and intact for 13.5% of CVADs (n = 35), and non-sterile dressings used to reinforce 26.4% of CVADs (n = 69). Almost half of CVADs (49.4%; n = 132) had no documentation regarding site assessment in the previous 4 h, and 13.4% had no planned use in the next 24 h (35 CVAD). CVAD-associated complications within the previous 7 days were evident in 9.5% of CVADs (n = 27), most commonly catheter blockage (5.7% CVAD, n = 15), and bloodstream infection (1.9% CVAD, n = 5). Peripherally inserted central catheters (16.9%) in comparison to other catheter types (7.4%; P = 0.04), and subsequent CVADs (14.1%) in comparison to initial CVADs (6.5%; P = 0.04), had significantly higher proportions of CVAD-associated complications in the previous 7 days. Variation between the sites' guidelines was evident across many practices.Conclusions: CVADs are prevalent and essential for paediatric health care; however, complications remain a significant problem. Areas identified for improvement were local CVAD guidelines, regular documentation of CVAD site assessment and review of dressing products to improve integrity. [ABSTRACT FROM AUTHOR]